Dental Benefits - Savannah State University

Group Dental
Dental Benefits
Savings, flexibility and service. For healthier smiles.
If I want to be at my best,
a good dental plan
will be refreshing.
F
O
O
A lot of emphasis has been put on healthy living recently, and oral health is an essential part of that.
PR
This dental benefit plan offers you valuable coverage to help you and your family keep a healthy
regimen. Plus, you’ll get the savings* you need, the flexibility you want and the service you can count
on. Now that’s refreshing.
• Lower costs.
• Freedom of choice.
• A commitment to your oral health.
D
• Less paperwork. Less worries. More Service.
RR
* Savings from enrolling in a dental benefits plan will depend on various factors, including how often participants visit the dentist
and the cost of services covered.
Table of Contents
Allow Us to Introduce Ourselves
Understanding Your Dental Plan
Board of Regents of the University System of Georgia Benefits
The MetLife Dental Education Center
We're Here to Help — MetLife Is at Your Service
Dear Board of Regents Employee:
The need for good dental benefits is essential for good oral health. The Board of Regents
provides you with access to a flexible dental benefits plan administered by MetLife — so you
and your family can receive the dental care you need, with features you deserve:
• Lower costs with benefits that provide access to coverage for preventive, basic, and complex
procedures that can help maintain long-term good oral health.
• Freedom of choice to visit any dentist without having to pre-select and commit to a specific
dental practice. Plus you don’t have the hassle of needed a referral to visit a specialist.
• A commitment to your oral health means educational tools and resources that help you and
your dentist make informed choices.
• Less paperwork, less worries and more service with easy access to pre-treatment
estimates, real-time claims processing* and 24-hour customer service by phone, fax or online.
It’s easy to get these valuable dental benefits.
• For more information, please visit www.metlife.com/mybenefits or call 1-866-832-5759.
• Your group premium will be paid through convenient payroll deductions.
Sincerely,
MetLife
* Transactions are in real-time except when systems are undergoing scheduled or unscheduled maintenance or interruption.
This dental benefits plan is made available through a self-funded arrangement. MetLife administers this dental benefits plan, but
has not provided insurance to fund benefits. Please contact MetLife or your plan administrator for complete details.
© 2008 Metropolitan Life Insurance Company, New York, NY
L05083102(exp1209)(All States)(DC,GU,MP,PR,VI)
Understanding Your Dental Plan
MetLife helps you get the dental coverage you and your family need. And with these valuable
features, your dental benefits are sure to keep you smiling:
x
x
x
x
Lower costs.
Freedom of choice.
Commitment to your oral health.
Less paperwork. Less worries. More service.
Lower costs for covered and non-covered services.
The MetLife Preferred Dentist Program (PDP) offers you plan benefits based on negotiated fees that
typically range from 10% to 35% less than the average fees for the same or similar services charged
by dentists in your area.1 All PDP dentists have agreed to MetLife negotiated fees for in-network
services - even for those services not covered by your plan and those provided after you’ve exceeded
your annual benefits maximum.
Freedom of choice.
With MetLife, you can go to the dentist you’re most comfortable with, even if he or she isn’t in our
network. But with nearly 110,000 in-network dentist locations, there’s a good chance your dentist is
part of the MetLife PDP. And if you need to find a dentist, you can easily find one in our national
network. Plus, you’ll be assured they’ve passed a rigorous selection process. In fact, 94% of patients
who visited an in-network dentist were satisfied with the quality of care they received.2
Commitment to your oral health.
The right dental care is an essential part of good overall health. That’s why we developed MetLife’s
Quality Initiative Program to promote good dental health. By providing dentists with access to
materials relevant to the latest dental research and trends in patient care, they can stay abreast of the
latest developments and technologies in oral health. Plus, it gives you tools to make better choices
about your dental benefits and health.
Today, the Academy of General Dentistry tells us that more than 90% of all diseases produce oral
signs and symptoms. Dentists now play a key role in screening for conditions such as cancer,
diabetes, leukemia, heart disease, and kidney diseases.3
Understanding Your Dental Plan (continued)
Less paperwork. Less worries. More service.
With MetLife, there’s no paperwork if your dentist submits your claims for you. We can even give you
pre-treatment estimates while you’re at the dentist.
Plus, anytime you want to check coverage, claim status or history, or get an estimate, you or your
dentist can get a quick answer by phone, fax or online, so you can get the information you want,
when you want it.
1. Savings from enrolling in a dental benefits plan will depend on various factors, including how often participants visit the
dentist and the cost of services covered.
2. 2007 MetLife Plan Participant Satisfaction Survey. Results based on participants who visited a MetLife PDP dentist and
reported that they are very satisfied or somewhat satisfied.
3. Academy of General Dentistry. The Importance of Oral Health to Overall Health,
http://www.agd.org/public/oralhealth/Default.asp?IssID=320&Topic=O&ArtID=1289#body, updated February 2007.
L05082931(exp1209)(All States)(DC,GU,MP,PR,VI)
Board of Regents of the University System of Georgia Dental Plan Benefits
For the savings you need, the flexibility you want and service you can trust.
Benefit Summary
SELECTED PLAN FEATURES AND
COVERED SERVICES
PLAN PROVISIONS AND BENEFITS
Annual Deductible Per Covered Member
$50
Annual Plan Maximum Per Covered Member
$1,200
Lifetime Maximum Orthodontic Benefit Per
Covered Member
$1,000
Preventive Dental Care
• Dental exam and routine scaling and cleaning
of teeth (limited to two instances in any one
calendar year);
• Topical application of sodium fluoride or
tannous fluoride to teeth, every 12 months for
covered members under age 19;
•
•
•
Dental x-rays - Full mouth x-rays are
limited to one every 60 months. Bitewings
are limited to 1 per year for adults and 1
every 6 months for children;
100% of PDP Fee*; not subject to deductible.
Members who elect to use non-network dental
providers will be subject to balance billing.
Space maintainers to replace prematurely lost
teeth; and
Sealants for permanent teeth (limited to
covered dependent children between the
ages of 6 years and 18 years, once per tooth
every 36 months).
Basic Dental Care
• Fillings to restore diseased or broken teeth
(multiple fillings on a single tooth surface will
be considered as a single filling).
• Extraction of a tooth that is not impacted;
• General anesthesia when used in conjunction
with oral surgery or other dental treatment,
and, determined to be medically necessary;
• Injections of antibiotic drugs;
• Endodontic treatment, including root canal
therapy; and,
• Periodontal treatment, including
gingivectomy, and treatment of other
diseases of the gums and tissues of the
mouth.
80% of PDP Fee*; subject to deductible.
Members who elect to use non-network dental
providers will be subject to balance billing.
Benefit Summary (continued)
SELECTED PLAN FEATURES AND
COVERED SERVICES
Restorative Dental Care
• Inlays, onlays and crowns;
• Repairs or recementing of crowns, inlays,
bridgework or dentures as well as the relining
of denture;
• Bridge pontic;
• Oral surgery;
• Osseous surgery;
• Initial installation or addition of full or partial
dentures or fixed bridgework, if they are
necessary as the result of injured or diseased
natural teeth being extracted, while covered
under this plan;
• Replacement or alternation of full or partial
dentures or fixed bridgework, if necessary as
a result of an accidental injury requiring oral
surgery, or oral surgery treatment involving
the repositioning of muscle attachments, or
the removal of a tumor, cyst, torus or
redundant tissue, while covered under the this
plan.
Restorative Dental Care (continued)
• Replacement of full denture, if it is required as
the result of structural change within the
mouth, and if it is made more than five years
after the denture was installed; and
• Replacement of a crown, if the replacement is
made more than five years after the crown
was installed.
Orthodontic Dental Care
• Including orthodontic appliances and
treatment received during the orthodontic
treatment. Orthodontic dental care will begin
after one is covered by the plan.
These services include, but are not limited to:
• Preventive treatment procedures;
• Removable or fixed appliance therapy; and
• Treatment of transitional and permanent
dentition.
PLAN PROVISIONS AND BENEFITS
80% of PDP Fee*; subject to deductible.
Members who elect to use non-network dental
providers will be subject to balance billing.
80% of PDP Fee*; subject to deductible.
Required waiting period of at least 2 years
following enrollment in the plan.
Members who elect to use non-network dental
providers will be subject to balance billing.
80% of PDP Fee*; subject to deductible.
Required waiting period of at least 6 months
following enrollment in the plan.
Members who elect to use non-network dental
providers will be subject to balance billing.
Lifetime benefit limit of $1,000.
* PDP Fee refers to the fees that participating PDP dentists have agreed to accept as payment in full, subject to any copayments,
deductibles, cost sharing and benefits maximums.
PDP Savings Example
This hypothetical example* shows how receiving services from a PDP (in-network) dentist can save you
money.
Your Dentist says you need a Crown, Restorative Dental Care —
•
PDP Fee: $375.00
•
R&C** Fee: $500.00
•
Dentist’s Usual Fee: $600.00
IN-NETWORK
When you receive care from a
participating PDP dentist:
Dentist’s Usual Fee is:
$600.00
The PDP Fee is:
$375.00
Your Plan Pays:
80% X $375 PDP Fee
Your Out-of-Pocket Cost:
OUT-OF-NETWORK
When you receive care from a
non-participating dentist:
Dentist’s Usual Fee is:
$600.00
Your Plan Pays:
- $300
$75.00
80% X $500 R&C Fee
Your Out-of-Pocket Cost:
- $400.00
$200.00
In this example, you save $125.00 ($200.00 minus $75.00)…
by using a participating PDP dentist.
*Please note: This example assumes that your annual deductible has been met.
** R&C fee refers to the Reasonable and Customary (R&C) charge, which is based on the lowest of (1) the dentist’s actual charge,
(2) the dentist’s usual charge for the same or similar services, or (3) the charge of most dentists in the same geographic area for the
same or similar services as determined by MetLife.
Common Questions… Important Answers
Who is a participating Preferred Dentist
Program (PDP) dentist?
A participating dentist is a general dentist or specialist
who has agreed to accept MetLife’s negotiated fees
as payment in-full for services provided to plan
‡
participants. PDP fees typically range from 10-35%
below the average fees charged in a dentist’s
community for the same or substantially similar
services.
‡ Based on internal analysis by MetLife
How do I find a participating PDP dentist?
There are nearly 110,000 participating PDP dentist
locations nationwide, including over 25,000 specialist
locations. You can get a list of these participating
PDP dentists online at www.metlife.com/mybenefits or
call 1-866-832-5759 to have a list faxed or mailed to
you.
What services are covered by my plan?
All services defined under your group dental benefits
plan are covered. Please review the enclosed plan
benefits to learn more.
Does the Preferred Dentist Program (PDP)
offer any discounts on non-covered
services?
Yes. MetLife’s negotiated fees with PDP (in-network)
dentists extend to services not covered under your
plan and services received after your plan maximum
has been met. If you receive services from a PDP
dentist that are not covered under your plan, you are
only responsible for the PDP (in-network) fee.
May I choose a non-participating dentist?
Yes. You are always free to select the dentist of your
choice. However, if you choose a dentist who does
not participate in the MetLife PDP, your out-of-pocket
expenses may be more, since you will be responsible
to pay for any difference between the dentist’s fee
and your plan’s payment for the approved service. If
you receive services from a participating PDP dentist,
you are only responsible for the difference between
the PDP in-network fee for the service provided and
your plan’s payment for the approved service. Please
note: any plan deductibles must be met before
benefits are paid.
Can my dentist apply for PDP participation?
Yes. If your current dentist does not participate in the
PDP and you'd like to encourage him or her to apply,
tell your dentist to visit www.metdental.com, or call
1-877-MET-DDS9 for an application. The website and
phone number are designed for use by dental
professionals only.
How are claims processed?
Dentists may submit your claims for you which means
you have little or no paperwork. You can track your
claims online and even receive e-mail alerts when a
claim has been processed. If you need a claim form,
you can find one online at
www.metlife.com/mybenefits or request one by calling
1-866-832-5759.
Can I find out what my out-of-pocket
expenses will be before receiving a service?
Yes. With pre-treatment estimates, you never have to
wonder what your out-of-pocket expense will be. The
plan recommends that you request a pre-treatment
estimate for services in excess of $350. (This often
applies to services such as crowns, bridges, inlays,
and periodontics.) To receive a benefit estimate,
simply have your dentist submit a request for pretreatment estimate online at www.metdental.com or
call 1-877-MET-DDS9 (638-3379). You and your
dentist will receive a benefit estimate (online or by
fax) for most procedures while you’re still in the office,
so you can discuss treatment and payment options,
and have the procedure scheduled on the spot. Actual
payments may vary depending upon plan maximums,
deductibles, frequency limits and other conditions at
time of payment.
Exclusions
Some of the dental services, supplies or treatments that are not covered by the dental plan include, but
are not limited to:
• Those that exceed the Preferred Dentist Program contracted in-network rates for covered dental
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charges;
Those that are not medically necessary;
Treatment not performed by a dental provider or doctor;
Those that are provided by a immediate family member or household resident;
Treatment performed by a licensed dental hygienist who is not supervised by a dental provider;
Those that were received prior to being eligible for plan participation and coverage;
Treatment due to injury or illness that is covered under any Workers’ Compensation Law, occupational
disease law or similar laws;
Those charges incurred by a member from his/her dental provider for failure to keep a scheduled
appointment;
Those charges incurred for the completion of any forms required for benefits to be paid;
Services for which you are not required to pay, or, for services in which no charge would have been
made in the absence of dental benefits;
Charges for services or supplies that do not meet accepted standards of dental practice, including
charges for services or supplies that are experimental in nature;
Charges or expenses for procedures, appliances and restorations, other than full dentures used to split
or to change vertical dimension or to restore an occlusion;
Surgical extraction of impacted teeth, but not including partially erupted teeth;
To replace lost or stolen dentures and/or bridgework;
The installation, replacement, or alternation of dentures or fixed bridgework, other than those services
that are listed under covered services;
Charges associated with dietary planning for the control of dental cavities, oral hygiene instruction,
including plaque control, or training in dental care;
Charges incurred for which benefits are paid under any public plan of dental insurance for which a
covered person is eligible;
Charges for services or supplies received as a result of dental disease or injury due to an act of war,
declared or undeclared, or a warlike act in time of peace;
A crown, gold restoration, or bridge, if the tooth was prepared before you or your dependent were
covered by the plan;
Root canal therapy if the pulp chamber was opened before you or your dependent were covered by the
plan;
Continuation of orthodontic treatment if the treatment began prior to the member being covered by the
plan;
An appliance, or the alteration of an appliance, if the impression was made before you or your
dependent were covered by the plan;
Charges or conditions for which others are responsible;
Services or supplies received by a covered person before that individual is eligible for dental benefits;
Use of materials, other than fluoride, to prevent tooth decay;
Procedures that are cosmetic in nature (e.g. bleaching, whitening and bonding);
For training and/or appliance to correct or control harmful habits, including, but not limited to, muscle
training therapy (myofunctional therapy);
Night or occlusional guard appliances;
Services or supplies that are for cosmetic purposes, unless they are:
o Otherwise a covered expense and are necessary because of an illness or injury that
happened while you are covered or,
o Required for reconstructive surgery because of a congenital disease or abnormality of a
covered dependent that results in a functional defect;
For prescription or non-prescription drugs, vitamins, or dietary supplements;
For house or hospital calls for dental services;
For hospitalization costs;
For treatment of fractures and dislocations of the jaw;
Exclusions (continued)
• Charges for care, treatment, services or supplies to the extent that any benefit is provided by Medicare;
• Charges that were not considered to be a “covered expense”, due to a pre-determination of benefits;
• Charges for nitrous oxide, novocaine, xylociane, or any similar local anesthetic, when the charge is
made separately from a covered dental expense;
• For the following that are not included as orthodontic benefits: Retreatment of orthodontic cases,
changes in orthodontic treatments necessitated by patient neglect, or repair of an orthodontic
appliance; and
• Services or supplies for which benefits are otherwise provided under the plan or any other plan that the
System (or an affiliate) contributes to or sponsors.
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The MetLife Dental Education Center
Focus on Oral Health: Why Having the Right Dental
Coverage is Good for Your Health.
Maybe you have good oral health, but have you
considered how unexpected dental problems can affect
you or your family members? Or, maybe you have some
type of dental coverage now, but the question is – is it
enough?
Although much emphasis has been put on healthy living
these days, you may not have thought to include your
mouth as part of your health regimen. The fact is, more
and more studies are finding links between your oral
health and your overall health. According to the U.S.
Dept. of Health and Human Services, research has
revealed an association between dental disease and a
person’s increased risk for systemic conditions.1
When you consider how dental problems can affect
people of all ages — and how costly they can be to treat
— you may want to carefully consider whether you have
adequate dental coverage. With MetLife, you have access
to dental benefit plans with easy-to-understand coverage
and savings that extend to non-covered services.2
Did You Know?
According to the National Institute
of Health, tooth decay is one of
the most common health problems
among Americans, second only to
the common cold.3
Studies suggest that periodontal
(gum) disease during pregnancy
may be a factor in premature
births.4
There are over 400 medications
(prescription and over-thecounter) that can cause “dry
mouth” (xerostomia) which can
lead to plaque build-up, tooth
decay and gum disease.5
An estimated 35,000 Americans will
be diagnosed with oral cancer in
2008 — over 7,500 expected to die
of the disease during a twelvemonth period.6
Want to know if you or your family is at risk for dental disease?
Visit the dental education website at www.metlife.com/mybenefits for important tools and resources
to help you become more informed about dental care. The site contains Risk Assessment Guides and
information on many oral health topics.
1. U.S. Dept. of Health and Human Services. Oral Health in America: A Report of the Surgeon General — Executive Summary.
Rockville, MD: U.S. Dept. of Health and Human Services, National Institute of Dental and Craniofacial Research, National
Institutes of Health, 2000.
2. Savings from enrolling in a dental benefits plan will depend on various factors, including how often participants visit the
dentist and the cost of services covered.
3. U.S. National Library of Medicine and the National Institutes of Health. Medical Encyclopedia: Dental Cavities. Accessed
February 2006. http://www.nlm.nih.gov/medlineplus/print/ency/article/001055.htm
4. Lindhe, J., Karring, T., Lang, L.P., Clinical Periodontology and Implant Dentistry, (Chapter 16) fourth edition. London:
Blackwell Scientific, 2003 (pg. 372).
5. Bartels, Cathy L. “Xerostomia Information for Dentists.” Oral Cancer Foundation Cite. 7 July 2005. Oral Cancer
Foundation.www.oralcancerfoundation.org/dental/xerostomia.htm.
6. American Cancer Society. Cancer Facts & Figures 2008. Atlanta: American Cancer Society; 2008.
L05082932(exp1209)(All States)(DC,GU,MP,PR,VI)
MetLife Is at Your Service
Finding out if your dentist is in the Preferred Dentist Program
To find out if your dentist participates in the MetLife Preferred Dentist Program which currently
includes over 110,000 in-network dentist locations, logon to www.metlife.com/mybenefits or call
1-866-832-5759 to have a list faxed or mailed.
If your current dentist does not participate in the PDP, and you’d like to encourage him or her to
apply, ask your dentist to visit www.metdental.com or call 1-877-MET-DDS9 for an application. (The
website and phone number are designed for dental professionals only.)
MyBenefits Registration Overview:
www.metlife.com/mybenefits
MyBenefits provides you with a personalized, integrated
and secure view of your MetLife delivered benefits. You
can take advantage of self-service capabilities such as:
•
•
•
Check coverage or claim status
View an Explanation of Benefits (EOB) statement
Locate a participating PDP dentist
Simply go to MyBenefits (www.metlife.com/mybenefits),
and follow the easy registration instructions.
Make better decisions about your
dental benefits with online tools.
You also have access to the Dental
Procedure Fee Tool provided by
go2dental.com via the MyBenefits
website. This tool helps you
approximate the in-network (PDP fees)
and out-of-network fees* for dental
services in your area. Learn more about
fees for services such as exams,
cleanings, fillings, crowns, and more!
Quick Tips for Easy Dental Claim Filing
With MetLife, there’s no paperwork if your dentist submits your claims for you. Whether it’s you or
your dentist, filing a dental claim with MetLife is a simple process. And, by keeping the following tips
in mind, you can help make it even easier:
•
Bring a claim form with you to your appointment. A claim form is included in this enrollment
booklet.
•
You can obtain additional claim forms three easy ways:
1. Download them from the MetLife website at www.metlife.com/mybenefits. Simply click on
"Download Claim Forms" from the homepage.
2. Call 1-866-832-5957 to have a form sent to you. You don't have to speak with a live
representative to order a claim form ⎯ you can call 24 hours, 7 days a week, to utilize
MetLife's automated voice response system.
3. Contact your Human Resources Representative, who should have forms on hand.
•
Speak with your dentist about reimbursement arrangements before your appointment. Although
most dentists will accept the claim reimbursement directly from MetLife, some may prefer to
receive payment in-full before you leave your appointment. Since each dentist sets his or her
own policy, you should discuss these arrangements before you receive any services.
* Out-of-network fee information is provided by go2dental.com, Inc., an industry source independent of MetLife. This site does
not provide the benefit payment information used by MetLife when processing your claims. Prior to receiving services, pretreatment estimates through your dentist will provide the most accurate fee and payment information.
MetLife Is at Your Service (continued)
Still have questions?
Call 1-866-832-5759 or visit www.metlife.com/mybenefits.
Service
Website
Toll-Free Phone Number
www.metlife.com/mybenefits
1-866-832-5759
www.metdental.com
(website for dentists only)
1-877-MET-DDS9
(638-3379)
(number for dentists only)
Dental Education
www.metlife.com/mybenefits
N/A
Dental Fee Estimator Tool
www.metlife.com/mybenefits
N/A
• PDP Directory
• Plan Coverage Information
• Claim Status/Claim Forms
• General Information and
Frequently Asked Questions
• Applying for the MetLife PDP
• Pre-treatment Estimates
L05082932(exp1209)(All States)(DC,GU,MP,PR,VI)
Metropolitan Life Insurance Company, New York, NY
DENTAL ENROLLMENT/CHANGE FORM FOR Board of Regents
SECTION TO BE COMPLETED BY EMPLOYER
Name of Employer (Please Print)
Group Customer #
Board of Regents
307601
Employer’s Street Address
City
Date of Hire (Mo./Day/Yr.)
Work Status:
New Hire
Rehire
Report #
Sub Division
State
Zip Code
Branch
Employee’s Work Location
Coverage Effective Date (Mo./Day/Yr.)
Active
Retired
Disabled
On Layoff/Leave of Absence
Hourly Paid
Salaried
Hours Worked Per Week
Full-Time
Part-Time
Original COBRA Effective Date (Mo./Day/Yr.)
Reason for Enrollment:
New Coverage
New Hire/First Time Eligible
Change in Enrollment
Family Status Change (not applicable to new enrollments) Date (Mo./Day/Yr.)
SECTION TO BE COMPLETED BY EMPLOYEE
Name (print)
First
Middle
Address Street
Last
Social Security #
City
State
E-mail Address
Zip Code
Date of Birth (Mo./Day/Yr.)
Male
Female
Marital
Single
Married
Status:
Widowed
Divorced
Phone No. (include area code)
COVERAGE REQUEST DATA:
I have received and read a copy of my employer’s current announcement of the group plan. I want to be covered under the group plan for the benefits for
which I am or may become eligible, requested below.
I request the following coverage:
Coverage Options (Note: Only one of the following may be selected)
Employee Only
Employee + Spouse
Employee + Spouse + Child(ren)
Employee + Child(ren)
If applying for Dependent coverage (Spouse and Child), complete section below:
Number of dependents (including spouse)
Name of Spouse (Last, First, MI)
Date of Birth
Sex (M/F)
Name(s) of Child(ren) (Last, First, MI)
Sex (M/F)
Date of Birth
Is child a full-time student?
Yes
Yes
Yes
Yes
Please Retain A Copy of The Fully-Completed Form For Your
Records And Return The Original To Your Employer
(Continued on Following Page)
1
A2000NW 1 000445144 LAN
A2000NW (03/09)
Board of Regents (20091002)
DECLARATION SECTION
Each person signing below declares that all the information given in this enrollment form is true and complete to the best of his/her knowledge and belief.
The employee declares that he or she is actively at work on the date of this enrollment form.
For Changes Requested After Initial Enrollment Period Expires
I understand that if dental coverage is not elected, a waiting period may be required before I can enroll for such coverage after the initial enrollment period
has expired.
For Payroll Deduction Authorization By the Employee
I authorize my employer to deduct the required contributions from my pay for the coverage requested in this enrollment form. This authorization applies to
such coverage until I rescind it in writing.
Fraud Warning:
If you reside in or are applying for insurance under a policy issued in one of the following states, please read the applicable warning.
New York [only applies to Accident and Health Benefits (AD&D/Disability/Dental)]: Any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance containing any materially false information, or conceals for the purpose of
misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a
civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Massachusetts: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance
containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits
a fraudulent insurance act, and may subject such person to criminal and civil penalties.
New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and
civil penalties.
Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an
insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Kansas, Oregon, and Vermont: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact
material thereto may be guilty of insurance fraud, and may be subject to criminal and civil penalties.
Puerto Rico: Any person who, knowingly and with the intent to defraud, presents false information in an insurance request form, or who
presents, helps or has presented, a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the same
damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine no less than five thousand (5,000) dollars
nor more than ten thousand (10,000), or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail,
the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to a
minimum of two (2) years.
Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
All other states:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement
of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties.
Signature(s): The employee must sign in all cases. The person signing below acknowledges that they have read and understand the statements and
declarations made in this enrollment form.
Sign
Here
Employee Signature
Print Name
2
Date Signed (Mo./Day/Yr.)
Our Privacy Notice
We know that you buy our products and services because you trust us. This notice explains how we protect your
privacy and treat your personal information. It applies to current and former customers. “Personal information” as
used here means anything we know about you personally.
Plan Sponsors and Group Insurance Contract Holders
This privacy notice is for individuals who apply for or obtain our products and services under an employee benefit
plan, or group insurance or annuity contract. In this notice, “you” refers to these individuals.
Protecting Your Information
We take important steps to protect your personal information. We treat it as confidential. We tell our employees to
take care in handling it. We limit access to those who need it to perform their jobs. Our outside service providers must
also protect it, and use it only to meet our business needs. We also take steps to protect our systems from
unauthorized access. We comply with all laws that apply to us.
Collecting Your Information
We typically collect your name, address, age, and other relevant information. We may also collect information about
any business you have with us, our affiliates, or other companies. Our affiliates include life, car, and home insurers.
They also include a bank, a legal plans company, and securities broker-dealers. In the future, we may also have
affiliates in other businesses.
How We Get Your Information
We get your personal information mostly from you. We may also use outside sources to help ensure our records are
correct and complete. These sources may include consumer reporting agencies, employers, other financial institutions,
adult relatives, and others. These sources may give us reports or share what they know with others. We don’t control
the accuracy of information outside sources give us. If you want to make any changes to information we receive from
others about you, you must contact those sources.
We may ask for medical information. The Authorization that you sign when you request insurance permits these
sources to tell us about you. We may also, at our expense:
x
x
Ask for a medical exam
x Ask for blood and urine tests
Ask health care providers to give us health data, including information about alcohol or drug abuse
We may also ask a consumer reporting agency for a “consumer report” about you (or anyone else to be insured).
Consumer reports may tell us about a lot of things, including information about:
x
x
Reputation
Work and work history
x
x
Driving record
Hobbies and dangerous activities
x
Finances
The information may be kept by the consumer reporting agency and later given to others as permitted by law. The
agency will give you a copy of the report it provides to us, if you ask the agency and can provide adequate
identification. If you write to us and we have asked for a consumer report about you, we will tell you so and give you
the name, address and phone number of the consumer reporting agency.
Another source of information is MIB Group, Inc. (“MIB”). It is a non-profit association of life insurance companies.
We and our reinsurers may give MIB health or other information about you. If you apply for life or health coverage
from another member of MIB, or claim benefits from another member company, MIB will give that company any
information that it has about you. If you contact MIB, it will tell you what it knows about you. You have the right to ask
MIB to correct its information about you. You may do so by writing to MIB, Inc., 50 Braintree Hill, Suite 400, Braintree,
MA 02184-8734, by calling MIB at (866) 692-6901 (TTY (866) 346-3642 for the hearing impaired), or by contacting
MIB at www.mib.com.
Using Your Information
We collect your personal information to help us decide if you’re eligible for our products or services. We may also need
it to verify identities to help deter fraud, money laundering, or other crimes. How we use this information depends on
CPN–Inst–Initial Enr/SOH -2009
what products and services you have or want from us. It also depends on what laws apply to those products and
services. For example, we may also use your information to:
x
x
x
x
x
x
x
administer your products and services
perform business research
market new products to you
comply with applicable laws
process claims and other transactions
confirm or correct your information
help us run our business
Sharing Your Information With Others
We may share your personal information with others with your consent, by agreement, or as permitted or required by
law. For example, we may share your information with businesses hired to carry out services for us. We may also
share it with our affiliated or unaffiliated business partners through joint marketing agreements. In those situations, we
share your information to jointly offer you products and services or have others offer you products and services we
endorse or sponsor. Before sharing your information with any affiliate or joint marketing partner for their own marketing
purposes, however, we will first notify you and give you an opportunity to opt out.
Other reasons we may share your information include:
x
x
x
x
x
x
x
doing what a court, law enforcement, or government agency requires us to do (for example, complying with
search warrants or subpoenas)
telling another company what we know about you if we are selling or merging any part of our business
giving information to a governmental agency so it can decide if you are eligible for public benefits
giving your information to someone with a legal interest in your assets (for example, a creditor with a lien
on your account)
giving your information to your health care provider
having a peer review organization evaluate your information, if you have health coverage with us
those listed in our “Using Your Information” section above
HIPAA
We will not share your health information with any other company – even one of our affiliates – for their own
marketing purposes. If you have dental, long term care, or medical insurance from us, the Health Insurance
Portability and Accountability Act (“HIPAA”) may further limit how we may use and share your information.
Accessing and Correcting Your Information
You may ask us for a copy of the personal information we have about you. Generally, we will provide it as long as it is
reasonably retrievable and within our control. You must make your request in writing listing the account or policy
numbers with the information you want to access. For legal reasons, we may not show you anything we learned as
part of a claim or lawsuit, unless required by law.
If you tell us that what we know about you is incorrect, we will review it. If we agree, we will update our records.
Otherwise, you may dispute our findings in writing, and we will include your statement whenever we give your disputed
information to anyone outside MetLife.
Questions
We want you to understand how we protect your privacy. If you have any questions about this notice, please contact
us. When you write, include your name, address, and policy or account number.
Send privacy questions to:
MetLife Privacy Office, P. O. Box 489, Warwick, RI 02887-9954
[email protected]
We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide
this privacy notice to you on behalf of these MetLife companies:
Metropolitan Life Insurance Company
General American Life Insurance Company
SafeGuard Life Insurance Company
MetLife Insurance Company of Connecticut
SafeGuard Health Plans Inc.
CPN–Inst–Initial Enr/SOH -2009
2
CALIFORNIA HEALTHCARE LANGUAGE ASSISTANCE PROGRAM NOTICE TO INSUREDS
No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the
number listed on your ID card, if any, or 1-800-942-0854. For more help call the CA Dept. of Insurance at 1-800-927-4357.
To receive a copy of the attached MetLife document translated into Spanish or Chinese, please mark the box by the requested language statement below, and
mail the document with this form to:
Metropolitan Life Insurance Company
PO Box 14587
Lexington, KY 40512
Please indicate to whom and where the translated document is to be sent.
Servicio de Idiomas Sin Costo. Puede obtener la ayuda de un intérprete. Se le pueden leer documentos y enviar algunos en español. Para recibir
ayuda, llámenos al número que aparece en su tarjeta de identificación, si tiene una, o al 1-800-942-0854. Para recibir ayuda adicional llame al
Departamento de Seguros de California al 1-800-927-4357.
Para recibir una copia del documento adjunto de MetLife traducido al español, marque la casilla correspondiente a esta oración, y envíe por correo el
documento junto con este formulario a:
Metropolitan Life Insurance Company
PO Box 14587
Lexington, KY 40512
Por favor, indique a quién y a dónde debe enviarse el documento traducido.
NOMBRE
DIRECCIÓN
⏜彊崭岏㦜╨ᇭ㌷♾䘁㈦⏜彊♲巾㦜╨ᇭ㌷♾尐㻑劊巾❰⚠⇯♲巾㠖ↅ᧨㒥♾尐㻑⚠⇯䤋⥭㠖ↅ䤓₼㠖巾㦻ᇭⰑ榏◣┸᧨
嵚咃榊㌷䤓ID◰ₙ㓏䯉壮䭋᧤Ⱁ㦘᧥᧨㒥1-800-942-0854ᇭⰑ榏ᕡ⮩◣┸᧨嵚咃榊┯ね≬椹捷䑀偩1-800-927-4357ᇭ
䍉㟅♥椷棓MetLife㠖ↅ䤓₼㠖巾㦻᧨嵚▍指㷳椂承ⓜ䤓㡈㫕᧨₵⺖㠖ↅᗺ⚛㷳嫷₏∄掄⹓咂᧶
Metropolitan Life Insurance Company
PO Box 14587
Lexington, KY 40512
嵚㖖㢝倢劊巾㠖ↅ㟅ↅⅉ䤓Ɫ⚜♙⦿⧏ᇭ
Ɫ⚜
⦿⧏
CA LAP STANDALONE NOTICE
(09/08)
Notes
000445144 LANDENPODKT
MetLife has been offering dental insurance coverage for more than 45 years.
So we have the experience to provide you with a valuable plan that will keep you
smiling. Plus, we provide the resources you need to make educated decisions
about your oral health.
1900030630(0408)
© 2008 METLIFE, INC. L05082933(exp1209)(All States)(DC,GU,MP,PR,VI)
PEANUTS © United Feature Syndicate, Inc.
Metropolitan Life Insurance Company
200 Park Avenue
New York, NY 10166
www.metlife.com